There has long been an issue regarding reimbursements of medical costs made by insurance companies. Typically, a medical services or medical products provider will provide a particular service or product to a patient and bill an insurance company for some portion of the cost of that service or product. In some cases, the insurance company is responsible for the entire cost of the service or product, but in most cases, the patient is responsible for some portion of the cost for these services and products.
In their never ending pursuit to enhance their profitability, insurance companies force medical professionals and medical supply companies to accept decreased payments. These are sometimes referred to as “negotiated” rates. These negotiated rates can amount to a much lower amount than a medical professional or medical supply company had planned on charging for their services or products. As time goes on, the negotiated rates tend to have an adverse affect on profitability. One effect of the decreased profitability is that some medical professionals and medical supply companies are forced to go out of business. Another effect, unfortunately, can be that in order to make up for the lost profits, some medical professionals and medical supply companies engage in fraudulent behaviors. These fraudulent behaviors may, for example, include submitting requests for reimbursements for medical expenses to insurance companies for medical services that were not rendered to a patient or for medical products that were not supplied to a patient. Fraudulent acts such as this have, in the past, been considered victimless crimes, i.e., the only one getting hurt is the insurance company. Accordingly, not much attention has been paid to this issue until it has become apparent that the fraudulent behavior may be a source of rising healthcare costs.
Current systems that are used to monitor medical services that are provided to patients are outdated and can be costly. For example, some insurance companies transmit a notice to a patient after a medical service has been provided. The notice indicates that medical service that has been provided and the portion of the service that was covered by insurance company. This type of system carries out fraud prevention by putting the patient on notice of the type of service that a medical professional may be seeking reimbursement for. If the service did not occur, then a patient receiving the notification will likely contact the insurance company to clear up the discrepancy.
Several systems exist to conduct reviews of healthcare. For example, U.S. Pat. No. 5,359,505 to Little et al. discloses a healthcare payment and review system. The system reviews and adjudicates healthcare payment requests made by a healthcare provider for procedures performed. The system reviews the payment request based on user-specified review criteria. Such criterion may reflect contractual arrangements between payers, providers and patients, current, locally acceptable medical practices and patient and provider payment request patterns. To perform the review, the expert system obtains relevant prior payment requests and defines a master list of payable payment requests given current medical procedures. The system goes on to analyze the current payment request according to the relevant historical payment requests and the master payable list by applying user-defined interpretive rules to this information. Payment decisions are developed and reported based on the analysis.
Many times, medical services can only be provided to a patient when the patient is located the same location as the medical professional. There exist systems that track the location of patients. For example, U.S. Published Patent Application No. 2009/0204434 by Breazeale Jr. discloses a healthcare tracking system that obtains location-time data automatically generated by a mobile electronic device associated with a healthcare provider, and that correlates the location-time data with location of the healthcare patient. This system, however, is directed to assuring that patients are billed for procedures that have been performed. The location information of the patient is used to reflect a triggering event for billing purposes.
U.S. Published Patent Application No. 2007/0299776 by Frustaci et al. discloses a method for preventing medical fraud that uses a real time transmitted identification system to verify patient identification, location, time and medical service provider identification. The system verifies provision of services to an authorized service user by assigning a unique identifying number to each authorized service provider and by assigning a unique identifying number to each authorized service user. The system determines the likelihood that an insurance claim by a service provider is valid by defining the unique identifying feature of each of the authorized patients and for each of the authorized doctors. Accordingly, the system is directed to determining probabilities of whether or not a medical claim may be fraudulent. The Frustaci et al. '776 patent application discloses that the patient's physical location may be determined by an attached GPS system at the provided location. The system obtains the patient's and the provider's fingerprints, or other identifying feature, and transmits the identifying feature information to a service confirmation center in real time.
U.S. Pat. No. 7,421,399 to Kimmel discloses a method of discouraging healthcare fraud in conjunction with providing healthcare services to patients in which the patient provides a biometric signature. More specifically, the system uses biometric information unique to an individual combined with location information to create a persistent record indicating that a particular person was physically present at a particular place.